Introduction: Rabies is a neglected disease of poor and vulnerable populations whose deaths are rarely reported. Although rabies is 100% fatal, it is 100% preventable also, but unfortunately, lots of death is occurring around the year. With this, the present study was performed to assess the sociodemographic profile and awareness and practice regarding management of animal bite among patients attending Rabies Clinic of Burdwan Medical College and Hospital (BMC&H), Burdwan, India. Methodology: This study was conducted among 220 patients in Rabies Clinic of BMC&H, Burdwan, India, between July and December 2012. Information about sociodemographic characteristics, awareness, and practices of animal bite were collected. Results: More than half (120, 54.6%) of the participants got animal bite-related information from health personnel (doctors, nurses, etc.). Dog bite was seen in 80% (176) of the cases; interestingly, monkey bite was seen in 4.1% (9) of the cases. Nearly sixty-six percent (65.8%) patients were classified as Category III according to the World Health Organization classification of the severity of wounds. Almost half of the victims (102, 46.3%) washed wound with soap under running tap water, whereas 12.9% (28) had taken no action. Most of the animal bite victims (177, 80.5%) received injection of tetanus toxoid and anti-rabies vaccine following animal bite. Conclusion: The present study showed that more than half of the participants got animal bite-related information from health personnel (doctors, nurses, etc.) and 12.9% (28) had taken no action after animal bite. These indicate proper control of stray animals as well as right medical advice and adequate treatment of animal bite cases can reduce the incidence of rabies.

Rabies also known as hydrophobia is a zoonotic disease which can result in 100% mortality once symptoms of the disease develop. Rabies is present on all continents except Antarctica, but more than 95% of human deaths occur in Asia and Africa.[1] Of the estimated 55,000 annual deaths due to human rabies in the world, more than 33,000 fatalities are likely to take place in the South-East Asia Region including 20,000 (40% children, out of which 70% males) deaths in India.[2],[3] Rabies is reported in India throughout the year from all states except Lakshadweep and Andaman and Nicobar Islands.[4] Since rabies is not a notifiable disease in India and there is no recognized surveillance system of human or animal cases, the actual number of deaths may be much higher.[5] Most of the cases (about 97%) of rabies are due to bites from rabid dogs, followed by bites from other animals such as cat, cow, monkey, horse, pigs, and camels which can be reduced ensuring adequate animal vaccination and control, educating those at risk, and enhancing access to appropriate medical care.[5],[6]

More than 15 million people worldwide receive a postexposure vaccination to prevent the disease[1] In India, rabies affects mainly poor and vulnerable populations from lower socioeconomic status and children between the ages of 5–15 years in remote rural communities, but only a few parents sought medical advice, usually with delay.[2],[7]

The World Health Organization (WHO) continues to promote human rabies prevention through the elimination of rabies in dogs and wider use of the intradermal postexposure prophylaxis (PEP), reducing both volume and cost of cell-cultured vaccine by 60%–80%, now being implemented in India also.[6] However, success of this program will depend on awareness of rabies among primary care providers, general people, and their attitude toward dogs and informed health-care-seeking behavior following dog bites.[2] With this background, this study was conducted to find the sociodemographic profile of the patients attending Rabies Clinic of Burdwan Medical College and Hospital (BMC&H) and their awareness and practice regarding management of animal bite.

Methodology

This institution-based study was conducted in the Outpatient Department (OPD) (Rabies Clinic) of BMC&H, Burdwan, West Bengal, India, between July 2012 and December 2012.

Study population and selection criteria

All the patients/victims (or parents accompanying their children) except unwilling, moribund patients and those who did not give consent attending in Rabies Clinic of BMC&H, Burdwan, India, were included in the study.

Sample size

In a recent study on community perception regarding rabies prevention and stray dog control among adults in urban slums in Bengaluru, public opinion regarding the role of community in prevention of rabies was found to be 33.5%.[8] Now considering this prevalence of 33.5%, sample size (n) was found to be 198.51 by applying the formula n = Zα2 pq/d2.

Pre-designed and pre-tested semi-structured schedule was developed with the help of published literature and public health experts. The questionnaire was divided into two parts:

First part – Sociodemographic factors such as age, gender, area of residence, and educational and occupation details

Second part – items/questions related to awareness and practices in connection with health-care-seeking practices following animal bite such as biting animal, site of bite and number of wounds, time of bite, pet care practices and responsible dog ownership, history of any primary treatment, and patient's information about the animal bite.

Type of contact, exposure, and recommended PEP were assessed with standard guidelines.[4],[9],[10]

Data collection

Following ethical approval, study timing for data collection was fixed during OPD hours in Rabies Clinic of BMC&H, Burdwan, in consultation with respective hospital authority. Patients/victims (or parents accompanying their children) attending the clinic were contacted during that time period. They were explained about the purpose of the study and assured regarding confidentiality of information, and informed consent was taken in a previously prepared format.

Following this, information about their sociodemographic characteristics and socioeconomic status as per modified BG Prasad scale 2013,[11] questions related to awareness, and practices of animal bite was recorded in the schedule by the researcher. Review of the current and past treatment records such as OPD prescription slip and doctor's prescription had been scrutinized from each patient seeking health care. Clinical examination of each participant was done; female patients were examined in the presence of female attendants or public health nurse. Data collection was through complete enumeration method and continued till the desired sample size of 220 was achieved completely.

Qualitative information collection

Qualitative information to explore awareness and practice regarding animal bite management was collected by two focus group discussion till point of exhaustion, where six and eight participants participated, respectively, and opined regarding issues pertaining to the theme. The focus groups included both males and females who talked freely and were willing to participate. FGDs were conducted by the researchers; information was collected in writing by a reporter and also by voice recording to cross-check findings.

Statistical analysis

The collected data were entered in Microsoft Excel worksheet (Microsoft, Redwoods, WA, USA) and checked for accuracy, any duplicate, or erroneous entry. Data were presented in diagrams and tables. Bar and pie diagrams were used for discrete/categorical data and expressed in proportions. Statistical analysis was done in SPSS software, version 19.0 (Statistical Package for the Social Sciences Inc., Chicago, IL, USA).

Results

In our study, maximum (52, 23.5%) cases were from ≤10 years' age group followed by 19.4% (43) from 21 to 30 years' age group, 17.6% (39) in 11–20 years' age group, and least (18, 8.3%) was above 50 years' age group; the majority of the participants (139, 63%) were male. There was nearly equal representation (50.8% vs. 49.2% respectively) from rural and urban areas, including 15.4% cases from slum areas of urban residence. Sixty-eight percent participants were from joint families; more than half (54%) participants belong to class V (Rs. < 773), 40.3% in class IV (Rs. 773-1546), 4% in Class III (Rs. 1547-2577) and least 1.7% in class II (Rs. 2578-5155) socio-economic statusas per modified BG Prasad scale 2013.[11]

Among the respondents who were aware of rabies, the most common (54.6%) sources of information were health personnel followed by self (36.1%), 5.6% was from mass media (television/radio/newspaper/posters), and a negligible portion 3.7% was from family members/friends [Figure 1].

Dog bite was seen in most (176, 80%) cases, followed by 15.9% (35) cat bite and 4.1% (9) monkey bite. In the present study, 75% (165) of cases were bitten by street animals (mainly dogs) and rest 25% (55) of cases were bitten by pet animals; reportedly, 78.3% of cases were bitten by unvaccinated animals and only 21.7% of cases by animals (dogs, cats, and monkeys) with known vaccination status. Most of the victims (170, 77.2%) had history of bite on the lower limb, in 17.8% (39) cases on the upper limb while only 5% (11) of the cases bite took place in other body parts such as on head, neck &face, chest, abdomen and back [Table 1].

[Figure 2] showed that majority of the patients (65.8%) were classified as Category III according to the WHO classification of the severity of wounds; 32.4% of them had Category II wound, while only 1.8% had Category I bite.

Figure 2: Distribution of study participants according to their category of bite (n = 220)

[Table 2] showed that nearly half of the victims, i.e., 46.3% (102) knew and washed the wound with soap under running tap water, 32.4% with only water, and 21.3% of victims did wound toileting without water. On further inquiries, it was found that 12.9% of the patients had taken no action on being bit, 2.8% had applied spirit overwound, 7.4% washed the wound with water and antiseptic, 2.8% had applied lime and turmeric overwound, and 1.8% had alum on wound site [Figure 3].

Table 2: Distribution of study participants according to their knowledge and practices following animal bite (n=220)

Nearly half (106, 48.2%) of the victims visited health facilities (Rabies Clinic) on the same day of bite, 17.8% within 1–2 days, but 34% visited on or after 3 days. Again, 48.2% visited hospital first after being bitten, while 29.6% went to pharmacy shop and 18.6% consulted with quacks before attending Rabies Clinic, and only 3.6% directly consulted private practitioners. Most of them (80.5%) had taken injection of tetanus toxoid (TT) and anti-rabies vaccine (ARV) following animal bite. Only 55.5% of victims knew about multiple numbers of injections of ARV, 40.5% of victims knew about correct site of ARV, and it should be taken as soon as possible [Table 2].

In this study, maximum (23.5%) cases were children ≤10 years which is almost similar to the study done by Patle and Khakse in Yavatmal[12] (23% of cases were from 5 to 10 years). Tenzin et al. in Bhutan[13] and Dwivedi et al. in Gwalior[14] found more proportion of cases, i.e., 32.5% and 39.26%, respectively, in ≤10 years' age group. Majority of the participants (63%) were male which is similar to studies done by Tenzin et al.[13] but higher than studies done by Indu D in Thiruvananthapuram,[15] Ghosh et al. in Bangladesh,[16] and Mohanty et al. in Cuttack[17] (54.2%, 57.7%, and 49.01%, respectively).

In this study, majority (36.1%) were educated up to Class VIII and 24.1% of the study participants were illiterate, while 14.2% of the patients were illiterate in a study done by Ganasva et al. in Gujarat.[18]

The present study showed that mostly dog bite causes rabies as said by participants; most common (54.6%) sources of information were health personnel (doctors, nursing staff, health workers, etc.) followed by self (36.1%), 5.6% from mass media, and only 3.7% from family members/friends which are in consistence with other studies done by Herbert et al., Tenzin et al., and Ghosh et al.[8],[13],[16] Studies elsewhere found high awareness regarding rabies-related health information among participants; maximum information was from media, neighbors, and friends (28.5%).[2],[8]

In our study, most of the cases (80%) were of dog bite followed by cat bite (15.9%) and monkey bite (4.1%) which is similar to other studies.[17],[18] In the present study, 75% of cases were bitten by street animals and rest 25% by pet animals; reportedly, 78.3% of cases were bitten by unvaccinated animals and only 21.7% by animals with known vaccination status. Maximum victims had bites on the lower limb (77.3%) followed by upper limb (17.8%) which is similar to the findings of study by Rumana et al. in Bangladesh.[19]

Patle and Khakse showed that 52.53% of children were bitten by stray animal. About 23.96% had lacerated wounds and 44.01% on upper limb bite followed by 37.10% on the lower limbs; head and face were common in children <5 years.[12] Indu D showed that 64.2% bites were by domestic animals, 29.5% by stray animals and 6.3% by wild animals; among these 50.1% bites were in lower limb.[15] Singh and Choudhary found in their study that all were aware of rabies and 98.6% knew about rabies transmission by dog bite.[20]

We found that majority of the patients (65.8%) were in Category III, 32.4% were in Category II wound, while only 1.8% had Category I bites consistent with Mohanty et al.,[17] while predominantly Category II bite was found in other studies (73.91% and 83.8%).[14],[18]

In the present study, almost half of the participants (46.3%) knew and washed the wound with soap under running tap water which is similar to the findings of study done by Herbert et al. and Tenzin et al. (51.4% and 45% washed wound with soap and water at home before presenting to the hospital, respectively).[8],[13]

In the present study, 12.9% of the patients had taken no action on being bitten by animal, 2.8% had applied spirit, 7.4% washed with water and antiseptic, 2.8% had applied lime and turmeric, and 1.8% had alum on wound site. A similar study by Herbert et al. found only 6.5% tie cloth, 7% apply turmeric or other powders, but a large number (35.1%) did not know first aid.[8] Ghosh et al. found that 16% of victims applied lime chilli and 3.8% turmeric on wound site; only 11% cleaned with soap and water and 12% with plain water and 37% visited clinic without anything.[17]

In the present study, 80.5% had taken injection of TT and ARV following animal bite; 55.5% of victims knew about multiple numbers of injections of ARV, 40.5% of victims knew about correct site of ARV, and it should be taken as soon as possible. Singh and Choudhary[20] found only 31.1% would like to apply first aid following animal bite and 36.4% visited doctors and rest either do nothing (13.3%) or adopt some religious practices (19.2%) whereas Ganasva et al.[18] found that 93.8% approached private or government health facilities before coming to the ARV Clinic, but 80% reported within 24 h.

The present study found that 48.2% victims visited health facilities (Rabies Clinic) on same day of bite, 17.8% within 1-2 days but one-third participants (34%) made delay i.e, visited on or after 3 days; consistent with findings of Indu D in Thiruvananthapuram (58.8 % reported on same day).[15] Ghosh et al. in Dhaka found that 10.36% of children reported hospital in <1 h, 31.11% after 24 h, 16.82% within 3 days, and 14.29% after 3 days.[16]

A study revealed that 70.1% knew about treatment for rabies and 77.5% stated rabies a killer disease; 89.9% of dog bite victims received treatment but only 24.3% received vaccine; 2.1% victims died, and 68% of the victims took indigenous treatment after being bitten by animal which is in consistence with other studies in the rabies endemic countries by Ghosh et al. and Dhand et al.[16],[21]

In our study, 48.2% visited hospital first after being bitten, while 29.6% went to pharmacy and 18.6% consulted with quacks before attending ARV clinic, and only 3.6% directly consulted private practitioners. Herbert et al. found that 74.1% consulted a doctor after animal bite and 64.9% of those aware of rabies treatment preferred government hospitals like this study.[8] Singh and Choudhary[20] found that 75.1% of individuals know about the nearest health facility.

Both Tenzin et al.[13] and Ghosh et al.[16] had shown that maximum (91% vs. 85%) opined rabies prevention and control by regular vaccination of dogs, consistent with this study findings. Mucheru et al.[22] in Kenya found that participants with adequate rabies knowledge were more likely to have proper health seeking (80%) and handling practices (88%) of suspected rabid dog.

Conclusion and Recommendations

The present study showed that most of the cases (80%) were dog bites (75% by street dogs); 66% bites were Category III bites; even in case of pets, vaccination was inadequate. More than half of the participants got animal bite-related information from health personnel (doctors, nurses, etc.) still 12.9% (28) had taken no action after animal bite. These findings indicate that proper medical care of animal bite cases and control of street dogs can reduce the incidence of rabies in a long run. Health education campaigns are needed to make people aware of rabies, vaccination of pets, and importance of seeking timely medical care after an animal bite can help in reducing the morbidity and mortality due to animal bites.

Acknowledgment

Authors of this study want to give sincere thanks to Medical Superintendent Cum Vice Principal, BMC&H, Burdwan, and HOD, Department of Community Medicine, for their kind permission and support to conduct the study. We also thank the OPD attendants and nursing staffs for their cooperation and support in executing the study. We gratefully acknowledge all of the individuals who consented to participate in our study and spent their valuable time with us.

National Rabies Control Programme. National Guidelines for Rabies Prophylaxis and Intra-Dermal Administration of Cell Culture Rabies Vaccine. National Institute of Communicable Disease, Ministry of Health & Family Welfare, Government of India; 2007. Available from: http://www.ncdc.gov.in/Rabies_Guidelines.pdf. [Last accessed on 2012 Jul 01].

Singh US, Choudhary SK. Knowledge, attitude, behavior and practice study on dog-bites and its management in the context of prevention of rabies in a rural community of Gujarat. Indian J Community Med 2005;30:81-3. [Full text]